yes / Most of surgical simulators employ a linear elastic model to simulate soft tissue material properties due to its computational efficiency and the simplicity. However, soft tissues often have elaborate nonlinearmaterial characteristics. Most prominently, soft tissues are soft and compliant to small strains, but after initial deformations they are very resistant to further deformations even under large forces. Such material characteristic is referred as the nonlinear material incompliant which is computationally expensive and numerically difficult to simulate. This paper presents a constraint-based finite-element algorithm to simulate the nonlinear incompliant tissue materials efficiently for interactive simulation applications such as virtual surgery. Firstly, the proposed algorithm models the material stiffness behavior of soft tissues with a set of 3-D strain limit constraints on deformation strain tensors. By enforcing a large number of geometric constraints to achieve the material stiffness, the algorithm reduces the task of solving stiff equations of motion with a general numerical solver to iteratively resolving a set of constraints with a nonlinear Gauss–Seidel iterative process. Secondly, as a Gauss–Seidel method processes constraints individually, in order to speed up the global convergence of the large constrained system, a multiresolution hierarchy structure is also used to accelerate the computation significantly, making interactive simulations possible at a high level of details . Finally, this paper also presents a simple-to-build data acquisition system to validate simulation results with ex vivo tissue measurements. An interactive virtual reality-based simulation system is also demonstrated.

The present research examined remains found from the Winchester Site in Winchester, MA that have evidence for postmortem alteration. The author compared the assemblages from Point San Jose (Hart et al. 2019; Willey et al. 2018), Holden Chapel (Hodge 2013; Hodge et al. 2017), Medical College of Georgia (Blakley 1997; McFarlin and Wineski 1997; Terrell and McFarlin 1997), Milwaukee County Institutional Grounds (Dougherty and Sullivan 2017), Newcastle Infirmary (Chamberlain 2016), and Blockley Almshouse (Crist et al. 2017; Hynes 2005) regarding patterns in bone modification and their potential causes. The sawn assemblage consists of 1365 adult remains, 67 juvenile remains, and 13 nonhuman remains. The human adult sawn Winchester Site sample is composed of 19.7% cranial remains and 80.3% postcranial remains. The postmortem alterations found on the remains from the Winchester Site lack pathological changes surrounding them. Eight of the 17 (47.0%) nearly complete crania exhibit evidence for craniotomy. Postmortem trephinations are seen in three crania. Repetition of surgical procedure training is seen through the 349 transverse complete kerfs located on the postcranial remains. There are 125 sternal segments and 133 rib segments with evidence of sharp force trauma, potentially from thoracotomy. The postmortem alteration within the faunal assemblage can be attributed to butchery on the elements from cow, sheep, and unidentified mammal, and dissection on the elements from the dog and red fox. Implements utilized on the skeletal remains were a flat-bladed saw with 18 teeth per inch (TPI) and a trephine. The remains from the Winchester Site exhibit experimentation with kerf locations, most likely originating from surgical training practices.

With the growing adoption of laparoscopic surgery practices, high quality training and qualification of laparoscopic skills through objective assessment has become critical. While eye-gaze and instrument motion analyses have demonstrated promise in producing objective metrics for skill assessment in laparoscopic surgery, three areas deserve further research attention. First, most eye-gaze metrics do not account for trainee behaviors that change the visual scene or context that can be addressed by computer vision. Second, feedforward control metrics leveraging on the relationship between eye-gaze and hand movements has not been investigated in laparoscopic surgery. Finally, eye-gaze metrics have not demonstrated sensitivity to skill progressions of trainees as the literature has focused on differences between experts and novices although feedback on skill acquisition is most useful for trainees or educators. To advance eye-gaze assessment in laparoscopic surgery, this research presents a three-stage gaze based assessment methodology to provide a standardized process for generating context-dependent gaze metrics and estimating the proficiency levels of medical trainees on surgery. The three stages are: (1) contextual scene analysis for segmenting surgical scenes into areas of interest, (2) compute context dependent gaze metrics based on eye fixation on areas of interest, and (3) defining and estimating skill proficiency levels with unsupervised and supervised learning, respectively. This methodology was applied to analyze 499 practice trials by nine medical trainees practicing the peg transfer task in the Fundamental of Laparoscopic Surgery program. The application of this methodology generated five context dependent gaze and one tool movement metrics, defined three proficiency levels of the trainees, and developed a model predicting proficiency level of a participant for a given trial with 99% accuracy. Further, two of six metrics are completely novel, capturing feed-forward behaviors in the surgical domain. The results also demonstrated that gaze metrics could reveal skill levels more precisely than between experts and novices as suggested in the literature. Thus, the metrics derived from the gaze based assessment methodology also shows high sensitive to trainee skill levels. The implication of this research includes providing automated feedback to trainees on where they have looked during practice trial and what skill proficiency level attained after each practice trial. / Master of Science / Laparoscopic surgery is type of minimally invasive surgery which is being widely adopted. Skills required for performing laparoscopic surgeries are different than open surgeries. Hence, it is critical to ensure that adequate training and assessment is provided to surgeons. Eye-gaze tracking technology has made it possible to compute metrics that could be employed for skill assessment. These metrics are based on involuntary gaze behaviors and are independent of the nature of the surgical training task being performed. Hence, they may not be suitable for feedback during training. Metrics suitable for feedback are context dependent metrics which take into account the task based information. Experts tend to show look-ahead behavior while performing a task which can be quantified using context dependent metrics. This research presents a three stage methodology which facilitates computation of context dependent metrics and feed-forward metrics enabling identification of different skill levels in trainees. Applying this methodology to dataset of nine trainees with 499 practice trials, a total of six metrics were computed and a classification model was built to predict three identified skill level with 99% accuracy. This research is directly applicable to developing an automated system for laparoscopic training and assessment.

<p>Robotic-assisted surgery (RAS) is one of the most significant advancements in surgical techniques in the past three decades. It provides benefits of reduced infection risks and shortened recovery time over open surgery as well as improved dexterity, stereoscopic vision, and ergonomic console over laparoscopic surgery. The prevalence of RAS systems has increased over years and is expected to grow even larger. However, the major concerns of RAS are the technical difficulty and the system complexity, which can result in long learning time and impose extra cognitive workload and stress on the operating room. Human Factor and Ergonomics (HFE) perspective is critical to patient safety and relevant researches have long provided methods to improve surgical outcomes. Yet, limited studies especially using objective measurements, have been done in the RAS environment. </p> <p> </p> <p>With advances in wearable sensing technology and data analytics, the applications of physiological measures in HFE have been ever increasing. Physiological measures are objective and real-time, free of some main limitations in subjective measures. Eye tracker as a minimally-intrusive and continuous measuring device can provide both physiological and behavioral metrics. These metrics have been found sensitive to changes in workload in various domains. Meanwhile, electroencephalography (EEG) signals capture electrical activity in the cerebral cortex and can reflect cognitive processes that are difficult to assess with other objective measures. Both techniques have the potential to help address some of the challenges in RAS.</p> <p> </p> <p>In this study, eight RAS trainees participated in a 3-month long experiment. In total, they completed 26 robotic skills simulation sessions. In each session, participants performed up to 12 simulated RAS exercises with varying levels of difficulty. For Research Question I, correlation and mixed effect analyses were conducted to explore the relationships between eye tracking metrics and workload. Machine learning classifiers were used to determine the sensitivity of differentiating low and high workload with eye tracking metrics. For Research Question II, two eye tracking metrics and one EEG metric were used to explain participants’ performance changes between consecutive sessions. Correlation and ANOVA analyses were conducted to examine whether variations in performance had significant relationships with variations in objective metrics. Classification models were built to examine the capability of objective metrics in predicting improvement during RAS training. </p> <p> </p> <p>In Research Question I, pupil diameter and gaze entropy distinguished between different task difficulty levels, and both metrics increased as the level of difficulty increased. Yet only gaze entropy was correlated with subjective workload measurement. The classification model achieved an average accuracy of 89.3% in predicting workload levels. In Research Question II, variations in gaze entropy and engagement index were negatively correlated with variations in task performance. Both metrics tended to decrease when performance increased. The classification model achieved an average accuracy of 68.5% in predicting improvements.</p> <p> </p> <p>Eye tracking metrics can measure both task workload and perceived workload during simulated RAS training. It can potentially be used for real-time monitoring of workload in RAS procedure to identify task contributors to high workload and provide insights for training. When combined with EEG, the objective metrics can explain the performance changes during RAS training, and help estimate room for improvements.</p>

The research presented in this thesis describes a substantial part of the design of a prototypical surgical training simulator. The results are intended to be applied in future simulators used to educate and train surgeons for bone milling operations. In earlier work we have developed a haptic bone milling surgery simulator prototype based on three degrees-of-freedom force feedback. The contributions presented here constitute an extension to that work by further developing the haptic algorithms to enable six degrees-of-freedom (6-DOF) haptic feedback. Such feedback is crucial for a realistic haptic experience when interacting in a more complex virtual environment, particularly in milling applications.The main contributions of this thesis are:The developed 6-DOF haptic algorithm is based on the work done by Barbic and James, but differs in that the algorithm is modified and optimized for milling applications. The new algorithm handles the challenging problem of real-time rendering of volume data changes due to material removal, while fulfilling the requirements on stability and smoothness of the kind of haptic applications that we approach. The material removal algorithm and the graphic rendering presented here are based on the earlier research. The new 6-DOF haptic milling algorithm is characterized by voxel-based collision detection, penalty-based and constraint-based haptic feedback, and by using a virtual coupling for stable interaction.Milling a hole in an object in the virtual environment or dragging the virtual tool along the surface of a virtual object shall generate realistic contact force and torque in the correct directions. These are important requirements for a bone milling simulator to be used as a future training tool in the curriculum of surgeons. The goal of this thesis is to present and state the quality of a newly developed 6-DOF haptic milling algorithm. The quality of the algorithm is confirmed through a verification test and a face validity study performed in collaboration with the Division of Orthopedics at the Karolinska University Hospital. In a simulator prototype, the haptic algorithm is implemented together with a new 6-DOF haptic device based on parallel kinematics. This device is developed with workspace, transparency and stiffness characteristics specifically adapted to the particular procedure. This thesis is focuses on the 6-DOF haptic algorithm. / QC 20120226

<p>A prototype of a haptic and virtual reality simulator has been developed for simulation of the bone milling and material removal process occurring in several operations, e.g. temporal bone surgery or dental milling. The milling phase of an operation is difficult, safety critical and very time consuming. Reduction of operation time by only a few percent would in the long run save society large expenses. In order to reduce operation time and to provide surgeons with an invaluable practicing environment, this licentiate thesis discusses the introduction of a simulator system to be used in both surgeon curriculum and in close connection to the actual operations.</p><p>The virtual reality and haptic feedback topics still constitute a young and unexplored area. It has only been active for about 10-15 years for medical applications. High risk training on real patients and the change from open surgery to endoscopic procedures have enforced the introduction of haptic and virtual reality simulators for training of surgeons. Increased computer power and the similarity to the successful aviation simulators also motivate to start using simulators for training of surgical skills.</p><p>The research focus has been twofold: 1) To develop a well working VR-system for realistic graphical representation of the skull itself including the changes resulting from milling, and 2) to find an efficient algorithm for haptic feedback to mimic the milling procedure using the volumetric Computer Tomography (CT) data of the skull. The developed haptic algorithm has been verified and tested in the simulator. The visualization of the milling process is rendered at a graphical frame rate of 30 Hz and the haptic rendering loop is updated at 1000 Hz. Test results show that the real-time demands are fulfilled. The visual and haptic implementations have been the two major steps to reach the over all goal with this research project.</p><p>A survey study is also included where the use of VR and haptic simulators in the surgical curriculum is investigated. The study starts with a historical perspective of the VR and haptic topics and is built up by answering different questions related to this topic and the implementation of simulators at the medical centres. The questions are of general concern for those developing surgical VR and haptic simulators.</p><p>Suggested future work includes modelling, development and validation of the haptic forces occurring in the milling process and, based on this, implementation in the simulator system. Also, further development of the simulator should be done in close cooperation with surgeons in order to get appropriate feedback for further improvements of the functionality and performance of the simulator.</p>

A prototype of a haptic and virtual reality simulator has been developed for simulation of the bone milling and material removal process occurring in several operations, e.g. temporal bone surgery or dental milling. The milling phase of an operation is difficult, safety critical and very time consuming. Reduction of operation time by only a few percent would in the long run save society large expenses. In order to reduce operation time and to provide surgeons with an invaluable practicing environment, this licentiate thesis discusses the introduction of a simulator system to be used in both surgeon curriculum and in close connection to the actual operations. The virtual reality and haptic feedback topics still constitute a young and unexplored area. It has only been active for about 10-15 years for medical applications. High risk training on real patients and the change from open surgery to endoscopic procedures have enforced the introduction of haptic and virtual reality simulators for training of surgeons. Increased computer power and the similarity to the successful aviation simulators also motivate to start using simulators for training of surgical skills. The research focus has been twofold: 1) To develop a well working VR-system for realistic graphical representation of the skull itself including the changes resulting from milling, and 2) to find an efficient algorithm for haptic feedback to mimic the milling procedure using the volumetric Computer Tomography (CT) data of the skull. The developed haptic algorithm has been verified and tested in the simulator. The visualization of the milling process is rendered at a graphical frame rate of 30 Hz and the haptic rendering loop is updated at 1000 Hz. Test results show that the real-time demands are fulfilled. The visual and haptic implementations have been the two major steps to reach the over all goal with this research project. A survey study is also included where the use of VR and haptic simulators in the surgical curriculum is investigated. The study starts with a historical perspective of the VR and haptic topics and is built up by answering different questions related to this topic and the implementation of simulators at the medical centres. The questions are of general concern for those developing surgical VR and haptic simulators. Suggested future work includes modelling, development and validation of the haptic forces occurring in the milling process and, based on this, implementation in the simulator system. Also, further development of the simulator should be done in close cooperation with surgeons in order to get appropriate feedback for further improvements of the functionality and performance of the simulator. / QC 20101112

Contexte: Les bénéfices associés à l’utilisation de sujets cadavériques en enseignement médical sont bien documentés et la maîtrise des dernières techniques endovasculaires est essentielle à la pratique quotidienne des chirurgiens vasculaires. Notre étude démontre la faisabilité d’élaborer un modèle cadavérique humain avec perfusion artério-veineuse antérograde pulsatile et chauffée pour une simulation endovasculaire fiable et reproductible. Méthodes: La canulation de sept sujets cadavériques conservés en solution saturée en sel a été réalisée pour permettre une perfusion centrale gauche-droite avec une solution chauffée, de l’aorte ascendante vers l’oreillette droite. Pour ce faire, nous avons utilisé des fistules artério-veineuses carotido-jugulaire et fémoro-fémorale créées chirurgicalement. Une pulsatilité de plus de 4.5 litres par minutes a été atteinte grâce à un prototype de pompe abordable conçue par des ingénieurs biomédicaux. La pression artérielle invasive et la température étaient contrôlées. Des séances de formation pour des procédures endovasculaires aortiques et des manipulations chirurgicales ouvertes ont été réalisées avec ce modèle. Résultats: Une perfusion cadavérique efficace a été possible pendant plusieurs heures, non seulement par voie artério-artérielle mais aussi avec une circulation artério-veineuse. La pression artérielle et les températures in situ ont reproduit fidèlement les fonctions vasculaires pour offrir des conditions similaires à la réalité. Ce nouveau modèle a permis de réaliser avec succès la mise en place d’une endoprothèse aortique thoracique (TEVAR), l’insertion d’un stent à l’artère sous-clavière gauche, et une simulation de la prise en charge chirurgicale ouverte d’une hémorragie sur traumatisme vasculaire. La méthode de conservation en solution saturée en sel et une pompe spécialement conçue ont amélioré la compétitivité des coûts. Conclusion: La simulation endovasculaire sur des sujets cadavériques, optimisée grâce au système de perfusion pulsatile et chauffé, peut être un complément dynamique à la formation chirurgicale et pour se familiariser avec de nouveaux instruments. Cet outil pédagogique reproductible pourrait trouver sa place dans tous les programmes d’enseignement chirurgical. / Abstract Background: The benefits of using cadaveric human subjects in surgical training are well documented and knowledge of the latest endovascular techniques is essential in the daily practice of vascular surgeons. Our study demonstrates the feasibility of developing an affordable human cadaveric model, with pulsatile and heated antegrade perfusion, for reliable and reproducible endovascular or surgical simulation. Methods: Cannulation of seven saturated-salt-solution embalmed human cadavers was undertaken to create a left-to-right central perfusion with a heated solution, from the ascending thoracic aorta to the right atrium. To that end, we used surgically created carotido-jugular and femoro-femoral arteriovenous fistulas. Pulsatile flow rate greater than 4.5 liters per minute was achieved with an affordable prototype pump designed by biomedical engineers. Invasive blood pressure and temperature were monitored. Training for endovascular thoracic aortic procedures and open vascular surgeries was performed using this model. Results: Effective cadaveric perfusion was achieved for several hours, not only with an arterio-arterial pathway but also with arteriovenous circulation. The arterial pressures and in situ temperatures accurately restored vascular functions for life-like conditions. This new model made it possible to successfully perform thoracic endovascular aortic repair (TEVAR), subclavian artery stenting, and simulation of abdominal open vascular trauma management. The saturated salt solution method and a specifically designed pump improved cost competitiveness. Conclusion: Endovascular simulation on human cadavers, optimized with the pulsatile and heated perfusion system, can be a dynamic adjunct for surgical training and familiarization with new devices. This reproducible teaching tool could be relevant in all surgery programs.

Background Force feedback is a critical element for performing and learning surgical suturing skill. Force feedback is impoverished or not present at all in non-open surgery (i.e., in simulation, laparoscopic, and robotic-assisted surgery), but it can be augmented using different modalities. This rapid, systematic review examines how the modality of delivering force feedback influences the performance and learning of surgical suturing skills. Methods An electronic search was performed on PubMed/MEDLINE, Web of Science, and Embase databases to identify relevant articles. The results were synthesized using vote counting based on direction of effect. Results A total of nine studies of medium-to-low quality were included. The synthesis of results suggests that the visual modality could be more beneficial than the tactile and auditory modalities in improving force control and that auditory and tactile modalities could be more beneficial than the visual modality in improving suturing performance. Results are mixed and unclear with regards to how modality affects the reduction of force magnitude and unclear when unimodal was compared to multimodal feedback. The studies have a general low level of evidence. Conclusion The low number of studies with low methodological quality and low level of evidence (most were proof of concept) prevents us from drawing any meaningful conclusion and as such it is currently unknown whether and how force feedback modality influences surgical suturing skill. Speculatively, the visual modality may be more beneficial for improving the control of exerted force, while auditory and tactile modalities may be more effective in improving the overall suturing performance. We consider the issue of feedback modality to be highly relevant in this field, and we encourage future research to conduct further investigation integrating principles from learning psychology and neuroscience: identify feedback goal, context, and skill level and then design and compare feedback modalities accordingly.

Addressing the shortage of healthcare professionals is critical for improving access to safe surgery in low- and middle-income countries. Patient safety precautions in surgical training include restricting the number of trainees present in the operating room, imposing limitations on how many surgeons can be trained simultaneously. The use of head-mounted cameras is suggested as a means to enhance and make surgical training more accessible by enabling remote viewing of surgical procedures from the surgeon's point-of-view. This research explores healthcare professionals' acceptance of incorporating a head-mounted smart camera as a complementary tool in surgical training. The case study, conducted during three surgical training workshops in Kenya and Ethiopia, utilized a modified UTAUT model. Questionnaires and five semi-structured interviews were employed, revealing a high level of technology acceptance. While some drawbacks were noted, overall positivity was expressed. The smart camera did in many ways align well with the needs of surgeons and anesthesiologists. Challenges mainly revolved around facilitating conditions such as poor connectivity and costs. Although the smart camera in many aspects enhanced the efficiency of surgical training, the findings highlight its inability to fully replace direct observation in the operating room.